Provider Demographics
NPI:1336902899
Name:HENDERSON, IRULAN ROSEMARIE
Entity type:Individual
Prefix:
First Name:IRULAN
Middle Name:ROSEMARIE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 RED BUCKEYE CT
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-8600
Mailing Address - Country:US
Mailing Address - Phone:203-731-7605
Mailing Address - Fax:
Practice Address - Street 1:1 CARRIAGE LN STE B102
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-6043
Practice Address - Country:US
Practice Address - Phone:203-731-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30238363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty